2Exercise in children and adolescents with diabetes
3Dr SAMANEH NOROOZI Pediatrician Pediatric Endocrinologist Assistant Professor of PediatricsBirjand University of Medical Sciences
4exercise is the third essential component in blood glucose regulation for persons with type 1 diabetes.the frequency of regular physical activitywas associated with lower HbA1c without increasing the risk of severe hypoglycemia.weight control, reduced cardiovascular risk, and an improved sense of wellbeing.
5Post-meal exercise can be a valuable way to minimize postprandial glycemic spikes . Diabetes should not limit the ability to excel in achosen sport.The topic most commonly discussed with families withregard to exercise is avoidance of hypoglycemia, butprevention of acute hyperglycemia/ketoacidosis maybecome a concern as well.
6Factors affecting glucose response to exercise Duration and intensity.Nearly all forms of activity lasting > 30 minutes will be likely to require some adjustment to food and/or insulin.repeated bouts of intensive activity interrupting longer periods of low to moderate intensity activity or rest produce a lesser fall in blood glucose levels compared to continuous moderate intensity exercise, both during and after the physical activity in young adults.
7Type of activity. Anaerobic efforts last only a short time (sometimes only seconds) but may increase the blood glucoselevel dramatically due to the release of the hormonesadrenaline and glucagon. This rise in blood glucoseis usually transient, lasting typically 30–60 minutes,and can be followed by hypoglycemia in thehours after finishing the exercise. Aerobic activitiestend to lower blood glucose both during (usuallywithin 20–60 minutes after the onset) and after theExercise.
8Metabolic control.Where control is poor and pre-exercise blood glucoselevel is high, circulating insulin levels may beinadequate and the effect of counter-regulatoryhormones will be exaggerated, leading to a higherlikelihood of ketosis.
9Blood glucose level Children with diabetes can have normal aerobic and endurance capacity if good glycemic controlis achieved (HbA1c <7.0%), even if they are slightly hyperglycemic at the time of exercise.Aerobic capacity is lower and the fatigue rate is higher in youth with type 1 diabetes when glycemic controlis less than optimal (i.e. HbA1c >7.5 %)cognitive performance has been shown to be slowerin youth with diabetes when their blood glucose is either hypo- or hyperglycemic
10Type and timing of insulin injections. When regular (soluble) insulin has been injected priorto exercise, the most likely time for hypoglycemia willbe 2-3h after injection and the high risk time after rapid-acting analog insulin is between 40 and 90 minutes.
11Type and timing of foodThe amount of carbohydrate should be matched as closely as possible to the amount of carbohydrate utilized during exercise, if a reduction in insulin is NOT performed. In general, approximately 1.0–1.5 g CHO/kg body weight/h should be consumed during exercise performed during peak insulin action in young adults with diabetes, depending upon type of activity.
12Short duration and high intensity anaerobic activities (such as weight lifting, sprints, diving and baseball) may not require carbohydrate intake prior to theactivity, but may produce a delayed drop in bloodsugar. For activities of these types, extra carbohydrateafter the activity is often the best option toprevent hypoglycemia
13lower intensity aerobic activities such as soccer (often described as a mixture between aerobic and anaerobic exercise), cycling, jogging and swimming will require extra carbohydrate before, possibly during and often after the activity.
14Absorption of insulin Choice of injection site Ambient temperature Heat also places additional stress on the cardiovascularsystem, resulting in greater energy expenditure and potential for a faster drop in blood glucose levels.
15Muscle mass/number of muscles used in the activity Using more muscles produces a greater drop in bloodglucose and weight bearing activities tend to use moreenergy than non weight-bearing activities
16Conditioning Patients frequently report that the drop in blood glucose may be less with regular conditioning andfamiliarity with the sport, although no experimentalevidence exists that tests this hypothesis.
17Degree of stress/competition involved in the activity The adrenal response will raise blood glucose
18Timing of the activityMorning activity, done before insulin administration,may not result in hypoglycemia as circulating insulin levels are typically low and glucose counter regulatoryhormones may be high .Indeed, severe hyperglycemia may occur with vigorous exercise in these circumstances, even precipitating ketoacidosis.
19Normal day to day exercise Where exercise is performed regularly, insulin sensitivityis generally enhanced.A positive association between glycemic control (i.e. HbA1c) and aerobic fitness or reported physical activity exists in youth with type 1 diabetes, suggesting that either increased aerobic capacity may improve glycemic control or that good metabolic control maximizes exercise .An inverse relationship was observed between HbA1 level and the maximal work load in a study in diabetic adolescents
20Choice of insulin regimen Twice daily injections:It may be difficult to maintain very strict bloodglucose control on these regimens especially withdifferent levels of exercise throughout the week, butthe essential requirements of taking various forms ofcarbohydrate before, during and after exercise maybe even more important than for more adjustableregimens.
21Multi-injection regimens or insulin pumps: These regimens afford greater flexibility for serioustraining and competitive events. Both pre-exercisebolus and basal rates can be reduced before, duringand after exercise to help increase hepatic glucoseproduction and limit hypoglycemia
22Hypoglycemia If a child with diabetes is feeling unwell during exercise with signs and symptoms of hypoglycemia,glucose tablets or other form of quick-actingcarbohydrate should be given as for treatment ofhypoglycemia, even if blood glucose cannot bemeasured to confirm hypoglycemia.• To treat hypoglycemia with a rise in BG of approximately3–4 mmol/L (55–70 mg/dl), approximately9 g of glucose is needed for a 30 kg child (0.3 g/kg)and 15 g for a 50-kg child.
23exercise for >1 hour can lead to increased insulin sensitivity and therefore an increased risk for hypoglycemia for at least 24 hours.
24Intensity of exercise 30 minutes 60 minutes Low (∼25% VO2 max 25% 50% Duration of exercise and recommended reduction in insulinIntensity of exercise30 minutes60 minutesLow (∼25% VO2 max25%50%Moderate (∼50% VO2 max75%Heavy (∼75% VO2 max)-
25Insulin pumps For certain types of exercise (like contact sports), it may be appropriate to disconnect prior to the startof the activity and remain disconnected for up to1-2h during an event. In these situations, patientsmay require a 50% bolus correction afterwards (ie.50% of the missed basal insulin while disconnected.
26KetonesIn situations of under-insulinisation, whether through systematically poor control or intercurrent illness, any exercise is likely to be dangerous because of the effect of uninhibited action of the counterregulatory hormones.Thus it isimportant for families to be warned about notparticipating in exercise if blood glucose is high andketones (small or more) are present in the urine or the level of beta-hydroxybutyrate (BOHB,‘‘blood ketones’’) in blood is > 0.5 mmol/L.
27Any exercise is dangerous and should be avoided if pre-exercise blood glucose levels are high(>14 mmol/l, 250 mg/dl) with ketonuria/ketonemia.Give approximately 0.05 U/kg or 5% of TDD (totaldaily dose, including all meal bolus doses and basalinsulin/basal rate in pump) and postpone exerciseuntil ketones have cleared.
28What to eat and drink When insulin is not reduced to accommodate for exercise, it is usually necessary to consume extracarbohydrate in order to avoid hypoglycemia. Thisis dependent upon type and duration of activity.The amount of carbohydrate needed depends largelyon the mass of the child and the activity performed aswell as the level of circulating insulin .Up to 1.5 grams carbohydrate per kilogram of body massper hour of strenuous exercise may be needed.
29While not confined to people with diabetes, the risk of dehydration should be borne in mind lest toomuch focus be kept upon glucose control. Evena 1% decrease in body mass due to dehydrationmay impair performance .In practice, both needs can often be met by using specially formulated drinks, but if dehydration is a risk, sugar free fluids should also be taken.
30Monitoring Measurements of glucose should be taken before, during and after the end of exercise withparticular attention paid to the direction of change inGlycemia. Monitoring several hours after exercise and before bed is particularly critical on days where strenuous activities occur, as nocturnal hypoglycemia is common.a bedtime bloodglucose of less than 7 mmol/l (125 mg/dl) suggested particular risk for nocturnal hypoglycemia .
31Diabetes complications patients that have proliferative retinopathyor nephropathy should avoid exercise conditions thatcan result in high arterial blood pressuresPatients with peripheral neuropathy shouldbe careful to avoid blisters and cuts and should avoidrunning and other sports that involve excessive wear oflegs and feet